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Purchase tickets for July 26, 2013: A Midsummer's Night with MedCentral Hospice:

        *First Name:        

        *Last Name:   

  *Street Address:    (Tickets will be mailed to the address provided)

                   *City:        

                 *State:        

                    *Zip:  

 *Phone Number:  

 

Ticket/Credit Card Information:

 # of Event Tickets to Midsummer's Night ($50 each or $90 for a couple):   

# of Raffle Tickets to Midsummer's Night ($50 each):  

   *Total Amount to be Charged to Credit Card:   $

                 *Credit Card Type:       

            *Credit Card Number:   

              *CVC2:     What's This?      (You'll need to confirm this on the next page) 

                   *Expiration Date:     (MMYY)

*Name as it appears on card:   

 

Privacy Policy Statement: Your personal information will not be
shared with anyone other than MedCentral Health System Hospice
and the payment processor to securely process this transaction.